Definition of Synoptic Reporting

Transcription

1 Definition of Synoptic Reporting The CAP has developed this list of specific features that define synoptic reporting formatting: 1. All required cancer data from an applicable cancer protocol that are included in the report must be displayed using a format consisting of the required checklist item (required data element), followed by its answer (response), e. g. Tumor size: 5.5 cm. Outline format without the paired required data element (RDE): response format is not considered synoptic. 2. Each diagnostic parameter pair (checklist RDE: response) is listed on a separate line or in a tabular format, to achieve visual separation. Note: anatomic site or specimen, laterality and procedure can be combined on the same line. For example: o Headers may be used to separate or group data elements o Any line may be indented to visually group related data elements or indicate a subordinate relationship o Text attributes (e.g., color, bold, font, size, capitalization/case, or o animations) are optional Blank lines may be used to separate data elements and group related elements 3. If multiple responses are permitted for the same data element, the responses may be listed on a single line. 4. The synopsis can appear in the diagnosis section of the pathology report, at the end of the report or in a separate section, but all RDE and responses must be listed together in one location. 5. Additional items (not required for the CAP checklist) may be included in the synopsis but all required RDE must be present. 6. Narrative style comments are permitted in addition to, but are not as a substitute for the synoptic reporting. It is not uncommon for narrative style comments to be used for clinical history, gross descriptions and microscopic descriptions. Additional Specifications and Options Data elements may be presented in any order in the report. Two data element names may not be listed on the same line, with the exception of anatomic site or specimen, laterality, and procedure as noted above. Otherwise, only multiple values pertaining to the same data element may be listed on the same line. Diagnostic headlines may be included that contain some data elements in nonstandard format (e.g., "INVASIVE CARCINOMA OF THE RIGHT BREAST.") However, if information in the headline includes a required element and the headline does not use the single line or multi-line format, the required information in the headline must also appear in the single line or multi-line format in the same report. Narrative comments may reference required or optional data elements. However, data elements and values that appear in narrative comment may not be properly abstracted and auditors are not to consider the data element and its value as having been included in a report, unless the information also appears in a properly formatted single line or multi-line statement. Data that are not listed as required or optional in an applicable cancer protocol may be included in any format. Examples include patient identification data (name, date of birth) or administrative data (report date, accession number) Required and optional data elements listed in the applicable cancer protocol may be combined into one report or broken up into separate reports. For example, separate paper reports or computer screens might be used to report

2 Definition of Synoptic Reporting Continued histological and molecular findings, or to report gross and microscopic findings, or to report examinations of different specimens. The CAP has developed a few examples of synoptic reporting (attached) for the use of the COC as training tools for COC inspectors. Sample reports 1-6 are examples of acceptable synoptic reporting; Sample reports 7 and 8 do not show acceptable synoptic style reporting. CAP recommends that CoC surveyors focus their evaluation of synoptic reporting only on definitive resection specimens and not biopsies at this time.

3 Synoptic Report Example #1 THYROID CARCINOMA Procedure: Thyroidectomy Specimen Integrity: Intact Specimen Size: 4.3 x 2.5 x 1.5 cm Right; 4.0 x 2.5 x 1.6 Left Tumor Focality: Unifocal, involves isthmus and right thyroid Tumor Laterality: Right lobe and isthmus Tumor Size: 2.5 cm Histologic Type: Papillary thyroid carcinoma Margins: Positive, right thyroid and isthmus Lymph-Vascular Invasion: Not identified Extrathyroidal Extension: Present Pathologic Staging (ptnm): Primary Tumor (pt): pt4a Regional Lymph Nodes (pn): pn1 Number lymph nodes examined: 3 Number lymph nodes involved: 1 Distant metastases (pm): pmn/a

4 Synoptic Report Example #2 CARCINOMA OF THE COLON OR RECTUM Specimen: Terminal ileum, cecum, appendix, ascending colon Other organs received: None Procedure: Right hemicolectomy Tumor site: Cecum Tumor size: 8.5 x 4.9 x 3.6 cm Macroscopic tumor perforation: Not identified Histologic type: Adenocarcinoma Histologic grade: High grade (poorly differentiated) Microscopic tumor extension: Tumor penetrates to the surface of the visceral peritoneum (serosa) Margins: Mesenteric: Involved by invasive carcinoma Proximal: Uninvolved by invasive carcinoma Distal: Uninvolved by invasive carcinoma Treatment effect: No prior treatment Lymph-vascular invasion: Present Perineural invasion: Not identified Tumor deposits (discontinuous extramural extension): Present Specify number of tumor deposits identified: 3 Pathologic staging (ptnm): Primary Tumor (pt): pt4a Regional Lymph Nodes (pn): pn1b Number lymph nodes examined: 25 Number lymph nodes involved: 3 Distant metastases (pm): pmn/a

5 Synoptic Report Example #3 CARCINOMA OF THE PROSTATE Specimen type: Prostatectomy Prostate weight: 47.20g Prostate size: 4.5 x 4.0 x 4.0 cm Histologic type: Adenocarcinoma Histologic grade (Gleason pattern): 7 Primary pattern: 3 Secondary pattern: 4 with focal 5 Total Gleason score: 7 Tumor Quantitation: Proportion (percent) of prostate involved by tumor: 15% Size of dominant nodule, if present, in mm: N/A Extraprostatic extension: Absent Seminal vesicle invasion: Absent Margins: Negative for malignancy Lymph-Vascular invasion: Absent Treatment effect: Absent Pathologic staging (ptnm): Primary Tumor (pt): pt2c Regional Lymph Nodes (pn): not applicable Number lymph nodes examined: 0 Number lymph nodes involved: not applicable Distant metastases (pm): pmn/a

6 Synoptic Report Example #4 ENDOMETRIAL CARCINOMA Specimen type (organs received): Uterus, bilateral ovaries and fallopian tubes, bilateral paraaortic lymph nodes Procedure: Hysterectomy and bilateral salpingo-oophorectomy; lymphadenectomy Lymph Node Sampling: Bilateral paraaortic Specimen Integrity: Intact Tumor Size: 1.3 cm Histologic Type: Endometrioid adenocarcinoma Histologic Grade: FIGO grade 2 Myometrial Invasion: Present Depth of invasion: 9 mm Myometrial thickness: 14 mm Involvement of Cervix: Present (stroma) Extent of Involvement of Other Organs: Bilateral paraaortic lymph nodes Margins: Negative for malignancy Lymphovascular Invasion: Absent. Pathologic staging (ptnm [FIGO]): TNM descriptors: y (post-treatment) Primary tumor (pt) ypt2 Regional lymph nodes (pn): ypn2 Pelvic lymph nodes: no nodes submitted Para-aortic lymph nodes: Number of lymph nodes examined: 12 Number of lymph nodes involved: 7 Distant metastases (pm): pmn/a

7 Synoptic Report Example #5 (This example combines specimen, laterality, and procedure on one line, as allowed) DUCTAL CARCINOMA IN SITU OF THE BREAST Specimen, Laterality, Procedure: Partial breast, right, excision without wire-guided localization Specimen Integrity: single intact specimen Specimen Size (for excisions less than total mastectomy): 8.2 cm in greatest dimension Lymph Node Sampling: No lymph nodes present *Tumor Site: Not specified Estimated size (extent) of DCIS (greatest dimension using gross and microscopic evaluation): at least 3.8 cm Histologic Type: Ductal carcinoma in situ. *Architectural Patterns: Solid Nuclear Grade: Grade II (intermediate) Necrosis: Present, focal (small foci or single cell necrosis) Margins: Margin(s) uninvolved by DCIS Distance from closest margin: 4 mm *Specify margins: *Distance from superior margin: 4 mm *Distance from inferior margin: >10 mm *Distance from medial margin: 6 mm *Distance from lateral margin: >10 mm *Distance from anterior margin: >10 mm *Distance from posterior margin: >10 mm Pathologic Staging (ptnm) Primary Tumor (pt): ptis (DCIS): Ductal carcinoma in situ Regional Lymph Nodes (pn): pnx pathologic study) (Cannot be assessed (not removed for Distant Metastasis (pm): Not applicable

8 Synoptic Report Example #6 (This example uses the CAP Cancer Checklist, as allowed) Gastrointestinal Stromal Tumor (GIST) Based on AJCC/UICC TNM, 7 th edition Procedure Excisional biopsy _X Resection Specify type (eg, partial gastrectomy): total gastrectomy Metastatectomy Other (specify): Not specified Tumor Site Specify (if known): gastric body Not specified Tumor Size Greatest dimension: _5.3 cm *Additional dimensions: _4.8 x _4.5 cm Cannot be determined (see Comment ) Other Features _X Unifocal Multifocal Specify number of tumors: Specify size of tumors: GIST Subtype Spindle cell Epithelioid X_ Mixed Other (specify): Mitotic Rate Specify: 2_ /50 HPF *Necrosis * X_ Not identified * Present *Extent: % * Cannot be determined

9 Histologic Grade GX: Grade cannot be assessed _x G1: Low grade; mitotic rate 5/50 HPF G2: High grade, mitotic rate >5/50 HPF Risk Assessment None Very low risk _X_ Low risk Intermediate risk High risk Overtly malignant/metastatic Cannot be determined Margins Cannot be assessed _X_ Negative for GIST Distance of tumor from closest margin: _3.2 cm Margin(s) positive for GIST Specify margin(s): AJCC/UICC Pathologic Staging (ptnm), 7 th edition: TNM Descriptors (if applicable) m (multiple) r (recurrent) y (post-treatment) Primary Tumor (pt) ptx: Primary tumor cannot be assessed pt0: No evidence for primary tumor pt1: Tumor 2 cm or less pt2: Tumor more than 2 cm but not more than 5 cm _X_pT3: Tumor more than 5 cm but not more than 10 cm pt4: Tumor more than 10 cm in greatest dimension Regional Lymph Nodes (pn) _X_ pn0: No regional lymph node metastasis pn1: Regional lymph node metastasis (In the absence of information on regional lymph node status, pn0 is appropriate; NX should not be used) Distant Metastasis (pm) _X_ Not applicable pm1: Distant metastasis *Specify site(s), if known:

10 *Ancillary Studies Immunohistochemical Studies KIT (CD117) X Positive Negative Others (specify): Not performed Mutational Analysis Performed Specify result: X_ Not Performed Preresection Treatment _X_ No therapy Previous biopsy or surgery Specify: Systemic therapy performed Specify type: Therapy performed, type not specified Unknown

11 Unacceptable synoptic Report Example #7 Diagnosis: Colon, right hemicolectomy: Invasive adenocarcinoma, 3.4 x 3.0 cm involving muscularis propria All margins negative No lymphatic invasion No metastatic tumor identified NOT ACCEPTABLE AS SYNOPTIC STYLE REPORTING: NOT ALL ELEMENTS ARE PRESENT AND DIAGNOSTIC PARAMETER PAIR IS ABSENT

12 Unacceptable Synoptic Report Example #8 Kidney Diagnosis: Kidney, Left (Radical Nephrectomy): Clear cell adenocarcinoma, Furhman nuclear grade 3, 8.3 cm, unifocal involving upper pole of kidney and extending into the renal vein with the renal vein margin positive. Sarcomatoid features not identified. No lymph nodes submitted, adrenal gland uninvolved, lymphatic invasion present, no venous large vessel invasion, pt3, Nx. No significant pathologic alterations identified. NOT ACCEPTABLE AS SYNOPTIC STYLE REPORTING: ALTHOUGH ALL REQUIRED ELEMENTS ARE PRESENT, INSUFFICIENT SYNOPTIC STYLE REPORTING